malingering

Faking pain – Is there a test for it?


One of the weird things about pain is that no-one knows if you’re faking. To date there hasn’t been a test that can tell whether you’re really in pain, or just faking it. Well, that’s about to change according to researchers in Israel and Canada.

While there have been a whole range of approaches to checking out faking such as facial expression, responses to questionnaires, physical testing and physical examinations, none of these have been without serious criticism. And the implications are pretty important to the person being tested – if you’re sincere, but someone says you’re not, how on earth do you prove that you’re really in pain? For clinicians, the problem is very troubling because allegations of faking can strain a working relationship with a person, and hardly lead to a sense of trust. Yet insurance companies routinely ask clinicians to make determinations about fraudulent access to insurance money – and worst of all, clinicians often feel they have little choice other than to participate.

In this study by Kucyi, Sheinman and Defrin, three hypotheses were tested: 1) Whether feigned performance could be detected using warmth and pain threshold measurements; 2) whether there were changes in the statistical properties of performance when participants were faking; and 3) whether an “interference” or distractor presented during testing interferes with the ability to fake and therefore provide a clue to when someone is being sincere or not.

Using university students (I hope they got course credits for participating!) who were not health science students, and were otherwise healthy, the investigators gave very little information about the procedure or hypotheses to minimise expectancy bias. Participants were then tested using a thermal stimulator to obtain “warmth sensation threshold” and “heat-pain thresholds” – this is a form of quantitative sensory testing (QST). TENS was used as a distractor in the experimental case, applied for 2 minutes before measuring the pain threshold, and during the heat pain threshold test. This was repeated with first the threshold test, then TENS. Participants were asked to pretend they were in an insurance office, being tested to establish whether they were experiencing genuine pain, after being told the test would be able to tell whether their pain was real.

What did they find out?

Well in situation one, where both threshold and warmth detection were used, and participants were asked to fake the pain intensity, respondents gave higher warmth detection ratings than normal. Not only this, but the ability to repeat the same response with the same temperature was poorer.  Heat pain threshold was also consistently different between the sincere and faked conditions, with heat pain threshold lower when people were faking (to around 3 degrees).

When the second testing option was carried out (using TENS to distract), heat pain threshold was significant lower when participants were faking, and the variance of the feigned + interference condition was three times that of the sincere condition, and the CV of the feigned + interference condition was twice that of the sincere condition.

What does this mean?

Well first of all, it means there are some consistent effects of faking in response to tests of warmth and heat-pain threshold when a distractor like TENS is used. Increased reports of warmth threshold and reduced heat pain threshold were observed, and where statistically significant. Interestingly, it was only when a distractor was used that the variability of reports were found – these authors suggest that people are pretty skilled at giving consistent reports when they’re not being distracted by an additional sensory stimulus.

Now here’s where I begin to pull this apart from a clinical and practical perspective. The authors, to give them credit, indicate that the research is both new and that it may identify some people who do have pain as malingerers. My concerns are that people with chronic pain may not look at all like healthy young university students.

We know very little about the responses to QST by people with different forms of chronic pain. We already know that people with impaired descending noxious inhibitory control respond differently to some forms of QST. We also know that contextual factors including motivation can influence how nervous systems respond to input. But my concerns are far more about the potential harm to those who are tested and found to be malingering when they’re not.

What do you do if you think a person is faking? How do you deal with this? What good does it do to suggest to someone their pain is not real, or isn’t nearly as bad as they make out? Once the words are out of your mouth (or written in a report) any chance of a therapeutic relationship has just flown right out the door. And you’re still left with a person who says they’re having trouble – but now you have an angry, resentful person who has a strong need to prove that they DO have pain.

You see, I think it might be more fruitful to ask why is this person faking pain? If it’s simply for money, surely there are far easier ways to get money than pretending to be disabled by pain? If it’s the case that a person is off out fishing or playing golf or living it up when “supposed” to be in pain, wouldn’t it make more sense to reframe their response as either recovering well (doing what’s healthy) and therefore get on with returning to work; or use a private investigator to demonstrate that he or she is actually capable of doing more than they indicate?

The presence or absence of pain is not really the problem, IMHO. To me we need to address the degree of disability that’s being attributed to pain and work on that. Maybe a greater focus on reducing disability rather than on expensive procedures to remove pain or otherwise get rid of pain is in order?

Kucyi, A., Sheinman, A., Defrin, R. (in press). Distinguishing feigned from sincere performance in psychophysical pain testing. The Journal of Pain.

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“Faking” pain – and inconsistency in presentation


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There is a common belief amongst some people involved in pain and pain management that a person with chronic pain should be consistent in their presentation. That is, be consistent in various settings, and consistent across various measures.  This assumes that if inconsistencies are present there must be something going on to cause suspicion about the validity of the person’s presentation.

Returning to yesterday’s post, I discussed the distinction between nociception (activation of receptors in the nervous system), pain (the experience produced by the brain once it has interpreted the nociceptive action), disability (the changes in functional performance attributed to the experience of pain), and impairment (tissue changes).  These are not the same! Today’s post refers mostly to pain and disability.

Pain is, as I keep spouting, a personal, subjective experience – you and I can’t share our pain except through our behaviour.  And even when we describe it, we can’t actually experience what it feels like to have each other’s pain. What this means is that our behaviours, or what we do, are what conveys our experience to others but only to a certain extent.

While our experience of pain remains individual, our behaviour is shaped by all the influences around us.  And just to make things more complex,  the meaning of our pain experience is shaped by what we learn and believe about pain from interactions between ourselves and all those influences that shape our behaviour. Complicated? Oh yes.

So if I grow up in a family that is generally stoic, where my complaints of pain are ignored and I see that others in my family don’t generally cry or stop doing things when they are hurt, it’s likely I’ll also be less demonstrative about my pain than another person in a family where this is not the norm.

We also learn to behave differently in different contexts. It’s common to say a few choice words when we hit our thumb with a hammer in the garage on a Saturday afternoon, but we usually wince and gasp quietly if we thump that same thumb in Church the next day!

What this means in terms of consistency is that people often do different things in different settings when they have pain – maybe when they drive from home to a clinic they’re a bit anxious about what the consultation might mean. They get out of the car and walk quite carefully into the clinic and sit down rather gingerly. They’re not sure whether they’re going to hear good news, or not. They go through the examination and consultation, and get told they’re going to try a new medication that might help. Oddly enough, as they walk back out to the car someone looking out the window might see them moving fluidly and getting into the car quite smoothly.  Suspicious minds might start to wonder if they really had “that much pain”.

Turning to assessment of pain now, it’s been said that pain assessment should incorporate a number of different dimensions. At the very least, assessment needs to consider the location of pain, the intensity and quality of pain, and some sort of measure of the interference pain has with everyday activities.  Some commentators consider pain assessment should also make a diagnosis of the type of pain disorder present (or the cause of the pain), while others also think that psychological aspects of pain need also to be included (such as pain catastrophising, measures of avoidance and measures of mood and anxiety). And of course, assessments of range of movement, strength and reflexes are also often part of a pain assessment.

Should these measures all present a “consistent” picture?

Where we hurt and what it feels like (the quality of pain) don’t directly correlate with the amount of interference a person experiences from their pain.  If I’m a pianist I might be really bothered by tingling and burning fingers, while less bothered about the same pain qualities in my feet.  If I’m really anxious about my future as a nurse, I might be really concerned about my low back pain. If I’ve developed some effective coping strategies for managing my overall body aching, I might not be particularly anxious or have low mood despite having quite intense pain.

Inconsistency between various aspects of a person’s presentation doesn’t mean they’re faking, or that their pain is not real. It does mean we need to generate some hypotheses about the relationship between the various factors that could be influencing the person’s behaviour. To decide, on the basis of our own experience (which is always limited!) that another person’s pain is not real just because we don’t understand why they are doing what they’re doing, is a judgement call we can’t make, in all honesty.  More than that, it doesn’t help work out what to do next to move the person from being disabled (or getting a benefit they don’t “deserve”) to returning to function.

Personally, determining the validity of a person’s claim to have pain is not the province of a health professional – it’s a task for administrators of a compensation scheme.  We can describe what we see, we might even make a diagnosis, but we can’t tell whether someone’s cheating the system. Bring out the investigators and be honest that health professionals can’t do what some insurers want us to.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0

The vexed question of determining whether pain is “real”


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Every now and then the old chestnut of whether it’s possible to determine if a person’s pain is “real” arises. Usually it’s in the form of an insurer, or maybe an employer, who wants to know if the pain this person is describing can possibly be as bad as the person says because

  • “they don’t look like there is anything wrong”
  • “there are these inconsistencies”
  • “it’s taken too long for them to recover”
  • “they’re not participating in their rehab”

For the avoidance of doubt, I have not been able to identify any readily available test or technology that can reliably determine what another person really experiences.

More than that, I’m not sure that it’s helpful in clinical practice to try to determine whether someone is “faking it”, and here’s why (sit back and get comfortable, this could take a while!).

Pain is not an actual or tangible thing.  We infer that someone has pain on the basis of their behaviour.  As Gatchel, Kishino and Minotti say “It is important to distinguish pain as a neurological event (nociception) from pain perception (which is subjective in nature).”  Nociception is about activation of receptors which pass through pathways to the central nervous system. Pain is the interpretation of this activation by the brain once it determines this information needs to be noticed and acted upon.  The same nociception activity in one person may not be perceived in the same way by another.

Having identified that pain is personal, we then turn to how a person responds to this event.  Gatchel, Kishino and Minotti remind us that pain, disability (the functional limitations, or behavioural expression of our individual experience of pain), and impairment (the physiological or physical findings) are not directly correlated.  While there is overlap, it’s not unusual to find someone with significant changes on x-rays and blood tests, who reports high levels of pain – but doesn’t let that stop them doing things.  At the same time, many painful conditions fail to show on x-rays or blood tests, but the person reports high levels of pain and finds it very difficult to carry out normal activities.

Why might someone’s disability from pain be greater than another persons?

That’s the million dollar question!And why it’s so important to obtain a biopsychosocial assessment of a person who is having trouble recovering because of pain.

We do need to understand the physiological processes involved in an individual’s presentation – knowing the diagnosis can be helpful, as can knowing the structural problems that underpin disability and pain.  At the same time, the science of diagnosis is not 100% reliable, and more importantly, unless there is a clear-cut treatment that can remediate the problem, searching for a diagnosis can play an important role in iatrogenic, or “resulting from the activity of physicians”, disability.

On to why identifying whether someone is faking it is unhelpful.

People with chronic pain have usually seen about 4 or 5 (or more) clinicians by the time they come to get a diagnosis of chronic pain.  Each time they see a new clinician, their history is repeated.  Clinicians are trained to find “what’s wrong” – and fix it. We get flummoxed when the person fails to “get better”. For some clinicians, it can mean repeating a treatment in the vague hope that what didn’t work the first time might work the fifth.  For others this failure can be turned on itself and (albeit inadvertently) the person with pain is seen as having “failed”. Maybe they weren’t motivated enough, maybe they didn’t really try hard enough, maybe they just don’t want to get better, maybe they don’t really have pain.

Patients can also be going through a process of feeling as though they’ve failed, maybe they’re not really motivated – maybe this pain is “all in my head”.

I don’t think many clinicians directly tell patients that they suspect they’re not really motivated, or don’t really have this much pain – but in a situation where the patient is already doubting, is anxious about recovery, and given our human tendency to jump to conclusions, it’s very easy for the person with pain to misinterpret what is going on.

In this situation – what do you think a person is likely to do if confronted by someone as to whether they might be “faking”? Hmmmm – I might just try to demonstrate how bad it is for me.  Chance of reducing disability has just dropped. And in the face of factors that reinforce disability such as family members who might be suggesting it’s risky to do anything “because the last time you did you were sore for ages!”, or coworkers who say “you look terrible, you need to go home”, or disability payments that are greater than unemployment benefits, or payment of a mortgage insurance that will make the house completely paid off – well, it’s probably quite hard to recover.

I’ve worked in pain management for 20 years or so, and I can’t tell whether someone is faking bad. I’ve met hundreds of people who say they have chronic pain, with an enormous range of factors that are working to hold the person in to their currently disabled situation. I have yet to find any medical, psychological or functional test (or combination of tests) that can determine the validity of the person’s pain and disability. And believe me, I’ve looked.

I’ll write more about this topic shortly – taking a look at psychological measures that have been suggested as ways to detect malingering or symptom magnification. I’ll also look at functional measures that supposedly show whether someone is giving “full effort”. In the meantime, I wonder whether it might be more useful to consider that a person’s self report of pain is what it is, and for clinicians to work at identifying the factors that could be responsible for maintaining disability.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0

The two faces of pain assessment


This week’s focus is on assessing or evaluating or getting to understand the experience of pain.  There are many reasons to assess someone’s pain, from trying to diagnose the kind of pain they have to attempting to see if someone is ‘real’ or not!  And shades in between.  I’m going to focus on ‘genuine’ reasons to understand someone’s pain experience rather than policing whether the person is a good actor or not, because as I’ve said before, I don’t think very often about people ‘faking’, and because I think it might be more helpful to try to see the world from the person’s eyes first.

So, given that pain is a multidimensional experience, why do I say there are two faces to pain assessment? Well the two I’m thinking of are:
(1) the experience of pain itself – location, quality, intensity etc, along with the beliefs and risk factors that influence the ‘suffering’ component of the ‘onion ring’ model described by Loeser and others.
(2) the impact of pain on function – disability, sleep loss, effect on relationships, work and so on.

I’m going to leave the first aspect for a while, and spend some time looking at the impact of pain on the individual and his/her family/community, but before I do I want to consider some basic concepts relevant to pain assessment that are essential before even beginning to think about the ‘how’ of assessment!

Firstly, all pain assessment is subjective. What that means is that as outside observers, we cannot determine whether the person is actually experiencing what they say (or indicate) they are experiencing. We can’t reliably establish whether someone is or is not carrying out activities to their full capacity. We can’t accurately determine whether a certain number of pain behaviours is the ‘correct’ amount of behaviour for the amount of nociception present.

Secondly, all behaviour is subject to the effects of learning and reinforcement that are well-established in the psychological literature (and in any two-year-old child wanting sweets!). As a result, it’s difficult to tell whether someone is behaving in a certain way because of years of learning within their family context, or whether it’s more immediate social environment demand characteristics that are influencing how the person is performing. We would all probably do more for someone that was holding a gun to our heads than for someone who looked bored (and we knew the results were going to determine whether we got some money!).

Thirdly, what we will or won’t do is also influenced by what we think we can or can’t do – and what we anticipate may happen afterwards, or what we experienced last time we attempted. A recent study of functional capacity evaluations found that even for people without chronic pain, a majority of participants experienced elevated pain the day after completing an FCE, so my guess is that some people who have chronic pain and who have completed a previous FCE may modify their performance at the next one. Our beliefs, attitudes, predictions, memories and so on determine what we are prepared to do in any context. When we look at the impact of pain on function, we need to remember this and take these factors into account.

The final area to consider today is the effect of context on performance. In many ways this is a summary of the three previous areas I’ve mentioned, but bear with me as I explain.
Many people with chronic pain report that they can carry out an activity in one setting, once, but when asked to carry it out repeatedly, and in a work setting, for example, they struggle. In the context of the real world, with all the social cues, cognitive load and need to persist and maintain activity over time, performance becomes variable. This doesn’t just happen for people with persistent pain mind you – let’s think of those Olympic athletes who may have performed well ‘at home’, but in the context of The Olympic Games in China in Front of All Those People – performance may well be very different.

I’ve only mentioned a few of the confounding factors that influence how pain may impact on a person’s daily activity in life and roles. I haven’t even started to use references – but you can bet if you come back this week, there will be more!

Faking and malingering (again!)


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One of the most popular posts I’ve written on this blog concerns ‘faking’ or ‘malingering’. I’m curious about this, because even though I have been asked many times whether I have had patients that are ‘faking’, I don’t think about it very often myself. I suppose it is a subject that is dear to the heart of anyone who is concerned about ‘motivation’ – especially where entitlements to payment or other benefits are dependent on the authenticity of the person’s claim to be unable to function.

So, time to unpack the whole topic again I think.

Last time I posted I had trouble finding relevant literature – the main problem being that in academic publications where pain is being discussed, the concept of faking has been superceded by research into areas we can work with clinically. The role of determining whether malingering or faking is not one for clinicians: it properly lives within the realm of private investigators – and even then, findings are up for challenge when a person is observed behaving in one way in one setting and another in a different setting. There are so many things that influence behaviour that it’s simplistic to decide that motivation to intentionally deceive is the primary reason.

If we start with the idea that pain itself is an experience – something we can’t share with each other, in the same way we can’t share whether we see the colour blue in the same way as each other, or the taste of banana! So you and I can’t tell just how much pain any person is in.

What we depend on is behaviour – what the person actually does behaviourally when they experience pain. And you and I know that we do different things in different places even when we experience the same pain! Take the example of stubbing your toe – in your garage you’ll probably swear loudly and jump up and down. In a very quiet church? Well, we probably won’t be able to hear your swearing and your jumping might be replaced with a wince…

In another example: if someone asked you to run 200m, you might take off at a bit of a gallop, but I’ll bet that if you knew there was a large and very angry bull coming after you, you might just move a little faster!

So we know that the social environment influences pain behaviour, and we also know that beliefs about the consequences of action also influence behaviour. We know too that what people understand about the significance of their pain is also a factor that changes behaviour. If you are unaware that the tickling feeling down your leg is actually a large and venomous spider biting you, you may well ignore it, if you think the vaguely tender lump under your armpit is cancer you’ll probably pay good attention to it and ask for a medical opinion. And your reaction to this lump might be even greater if you’ve had a history of cancer in your family.

In the compensation situation, there is no doubt that the security of receiving a weekly payment can be very helpful in the initial stages of recovery from an injury. That security can become problematic when the person is being asked to undertake the relatively risky business of returning to work – What if returning to work fails? What if my pain gets so bad that I can’t keep going? What if I let my employer down?

Some of these very realistic fears can interfere with the readiness for someone to return to work – and yes, compensation means it can easier to remain in status quo than to attempt to return to work. Does this equal malingering? Is the person faking? Or would you and I feel very much the same, and be quite hesitant to risk our health and livelihood too?

Can we as health professionals ‘tell’ whether someone is intentionally faking?

The short answer is no – humans are very poor at telling whether someone is lying. That’s why movies are so successful – even though we know the people are ‘actors’!

Take a look at this clip from You Tube:

And this one:

and the truth?

For another good article on deception – if a bit cognitive – this newly published article review the latest and greatest on the art of detecting deception. It’s just too early to apply this to pain and malingering.

SIP, K., ROEPSTORFF, A., MCGREGOR, W., FRITH, C. (2008). Detecting deception: the scope and limits. Trends in Cognitive Sciences, 12(2), 48-53. DOI: 10.1016/j.tics.2007.11.008

Fear/anxiety, pain and movement…


ResearchBlogging.org

The best way to start this week’s series of posts is by quoting Simmonds, Moseley & Vlaeyen (2008) who said: ‘Chronic pain and its often associated movement dysfunction are pervasive, intriguing and complex problems … conceptualisation of pain and movement dysfunction has increased our understanding of both…that conceptualisation remains incomplete until it also includes the mind.’

For many years, ‘reactivation’ has been the watchword for chronic pain management ‘functional’ programmes. This was predicated upon the belief that people with chronic pain became ‘deactivated’ or lost physical conditioning due to low levels of activity, and that if they were encouraged to get fitter they would return to normal function. An alternative option was to use the behavioural school of therapy, where positive health behaviour (to normalise activity level) was reinforced, mainly through therapist encouragement and self-monitoring, and by doing this the individual would return to normal function.

Problem was (and still is), a certain proportion of people just don’t engage in this type of programme, often becoming highly distressed, convinced they had been harmed because their pain increased (often with a raft of new symptoms developing also), and without another alternative, these people were either left without any reactivation or referred for ‘talk therapy’.

In the mid-1990’s, research into the model of pain-related anxiety and avoidance (commonly called the ‘fear-avoidance model’) was initiated, and the growing literature into this model since then has confirmed its value in working with people who develop high levels of avoidance.

Essentially, the model describes the two approaches an individual can take when experiencing pain – either avoidance, with subsequent loss of activity and engagement in life roles; or approach, with increasing re-engagement in activities despite short-term fluctuations in pain. Research has confirmed that it is not just the pain that is the problem, it is the fear and avoidance of pain (or to be quite pedantic, it is the anxiety about pain – fear is quite specific (Rachman, 1998), while anxiety is generalised, future-oriented and the ‘source of threat is more elusive without a clear focus’ (Leeuw et al. 2008)).

Further development of the model has identified some of the underlying thinking patterns that may influence the development of avoidance in response to pain – particularly health anxiety and negative affectivity. Health anxiety refers to the tendency to have catastrophic thinking patterns in response to threats of loss of body integrity, while negative affectivity is the tendency to see the glass half empty rather than half full.

For an excellent recent review of the ‘fear-avoidance’ model, Leeuw, Goossens, Linton, Crombez, Boersma & Vlaeyen (2007) have written in the Journal of Behavioural Medicine (30:1), February 2007.

My interest in posting on this model this week is to review the application of one of the treatment options suggested as a result of this model: exposure therapy. I’ve referred to this approach a couple of times before, in CRPS, in a pain management programme , in whether we are afraid to push our patients, and so on.

My interest currently is because I’m working with a young man who presents with extensive deactivation and loss of roles, depression and difficulty coping who identified almost 70 photographs from my set of 99 PHODA photographs as activities he would not do for fear of either increased pain or potential harm.

I was excited to find that the shortened electronic version of PHODA is available for free download, and I reported recently on a cervical spine version of the PHODA that has been published just a short while ago.

I’m also keen to see how I can integrate some of the work that has been carried out on mindfulness as it is applied to anxiety (eg Forsyth & Eifert, 2007) and whether this can be applied when helping people work through a hierarchy of feared activities.

So…an interesting week ahead!
BTW the three favourite (in terms of number of hits at least!) topics on this blog to date are: mindfulness, malingering and the CBT worksheet – so expect more soon!

Leeuw, M., Goossens, M.E., Linton, S.J., Crombez, G., Boersma, K., Vlaeyen, J.W. (2007). The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. Journal of Behavioral Medicine, 30(1), 77-94. DOI: 10.1007/s10865-006-9085-0

Rachman, S. (2004). Fear and courage: A psychological perspective. Sociological Research., 71, 149-176.

Simmonds, M. J., Moseley, G., & Vlaeyen, J. W. Pain, Mind, and Movement: An Expanded, Updated, and Integrated Conceptualization. Clinical Journal of Pain May 2008;24(4):279-280.

‘Faking’ or ‘Malingering’ or ‘Exaggerated Pain Behaviour’


Hot words!!

It’s amazing how often health providers get asked directly or indirectly whether someone experiencing pain is ‘faking’ it. The short answer is the most accurate – we can’t tell. We’re not lie detectors, there is no ‘gold standard’ to work out whether someone is pretending or not, and the question is based on erroneous thinking about pain and pain behaviour.

I can almost feel the spluttering at my last sentence from some readers!

Let’s look at this more closely.

Remember the biopsychosocial model of pain states that the experience of pain and pain behaviour is influenced by three broad groups of factors: the biomedical/biophysical factors such as extent of tissue disruption at the periphery (or site of trauma), neurological changes of transmission and transduction (throughout the peripheral and central nervous system), and disturbance of the neuromatrix.

At the same time, there are psychological factors such as the level of alertness and arousal, attention, past learning, expectations, beliefs, attitudes, mood, contingencies and so on.

And there is also a range of social factors such as the presence or absence of social support, the systems in which the event occurs (such as compensation, availability of health care and technology), cultural expectations, religious beliefs at the same time as the other two factors.

Recall that pain is not the same as pain behaviour – pain behaviour is everything that we do in response to pain, including involuntary physiological responses (flushing, sweating), reflexes (withdrawal), verbal utterances (groans, gasps, requests for help), as well as complex behaviours such as reaching for medication, going to see a doctor, asking for time off work etc.

Pain behaviour is subject to all the usual influences on any behaviour – that is, operant conditioning can be involved, as well as classical conditioning. And pain behaviour has developed from the behaviour we displayed as a baby to the more complex and modulated behaviours we demonstrate now.

So, it’s easy to see that pain behaviours vary hugely between individuals even if the original trauma is exactly the same.

I can understand several things about the question ‘can you tell if he’s faking’. Pain behaviour elicits strong emotions in observers – it’s designed to do just that! It communicates, and something we like to do as humans is work out whether someone is lying or not. The problem is – we’re not very good at telling who is and is not lying (but we like to fool ourselves that we personally don’t fall for liars!).

In a litigation or compensation situation, it would be great to work out exactly ‘how much’ each pain is worth in order to give it a dollar value, and determine compensation. But – pain can’t be measured directly, we have to use pain behaviour as the next best thing – and pain behaviours are influenced by a whole lot of things. So it’s not a very reliable measure.

Another reason for wanting to know ‘is he faking’ is how far to ‘push’ the person into doing more. The underlying concern is ‘will I cause harm’. And again we really don’t have any useful measure if we try to have pain or pain behaviour as our guide. We need to use something else – radiological union perhaps, control of a load, heart rate and respiration.

BUT the question is based on the assumption that there ‘should’ be a certain amount of pain behaviour for a certain amount (or length of time since) tissue damage. And there simply isn’t.

Some allied questions….‘can’t you use functional capacity testing to work out whether someone’s faking?’ No – sorry. A functional assessment, just like any physical examination or test, tells you what the person will do, and perhaps how consistently they will do it – today. Few, if any, FCE’s have demonstrated predictive validity – that is, they don’t accurately predict how much someone will or won’t do in a day-to-day ‘real’ situation, in fact they won’t tell you what the person can and cannot do at all.

What does this ‘consistency of effort’ tell me? Just that – how consistent this person carried out this activity this time. It doesn’t predict anything, and certainly doesn’t tell whether someone is ‘faking’. People vary in their consistency of performance depending on: their initial expectation of the activity (it may have been harder or easier than they first thought); their prediction of the effect of doing that activity (they may predict they will have an increase in pain – and therefore reduce effort, or perhaps increase effort in order to convince the examiner that they are trying hard); their fear/anxiety may vary throughout an activity; their past experiences may influence what they are prepared to do. Even when given the same instructions ‘use maximal effort’ – if a person hasn’t done anything very physical for a while, ‘maximal effort’ may be hard for them to predict. Some may even be ‘saving themselves’ for activities later in the assessment battery.

But surely some people do fake! Yes – but it’s not a health or medical matter. It’s just not helpful to work out whether someone is or isn’t faking. What happens if you do somehow detect ‘faking’? Confront the person? Take their health care away? Tell them to pull themselves together?

It’s more helpful to think about what factors might be initiating and then maintaining this behaviour – then start to work on these variables to promote change.

But I’ve seen even eminent researchers use the term ‘exaggerated illness behaviour’. Yes, well, even eminent researchers can be mistaken! All that we can observe is that this person behaves in this way at this time in this setting, and the person attributes the behaviour to pain (or illness). We can only identify all the possible factors that are contributing to the maintenance of the behaviour, elicit from the person the not so good things about the situation they find themselves in (and acknowledge the good things about their situation), and help increase the importance they place on making changes, and support their confidence to start to make changes. This might mean leveraging off contingencies (reducing compensation, withdrawing spouse support) if these things are maintaining the behaviour – but it may also mean simply resolving ambivalence about the positives of moving forward.

Malingering? Faking? Exaggerating? When someone can tell me why yellow is better than blue, or find a measure of the ‘chocolateness’ of chocolate and the banana-ness of a banana, perhaps we may have found an objective pain measure. Until then, don’t ask me to work out whether someone is faking it, just ask me to help them move forward.

Oh, and just for fun – how many different words are used to suggest that someone is ‘faking’?

– functional overlay

– supratentorial factors

– a ‘genuine’ man (as opposed to a fake one, or one that is faking)

– adopting the ‘sick role’ (if someone believes they are sick/unwell, what can we expect? How many people do we see ‘adopting the well role’?)

– demonstration of non-organic signs (now that one’s actually interesting, as Gordon Waddell states very clearly in his book ‘The Back Pain Revolution’ (2nd Ed), he never intended the term to mean anything other than to suggest the person was experiencing increased psychological distress – and NEVER to be used as a means of detecting faking!)

This paper by Michael Sullivan is a little philosophical, but at the same time illustrates the points I’ve tried to make above.
This reference is from the 2001 version of the New Zealand ‘Yellow Flags’ document on acute low back pain management.

It’s actually quite hard to come up with good (quality, evidence-based) references on ‘malingering’. By far the majority of articles I located using Google, searching on the terms ‘malingering pain behaviour’ suggested that somehow ‘medical people’ or ‘psychologists’ or ‘psychiatrists’ using special tests can identify malingerers. Someone please show me the ‘special test’!! This section of the IASP Core Curriculum should put to rest this sad aspect of the management of people experiencing persistent pain. Detection of malingering is best left up to private investigators, leaving health care providers to the really difficult work of helping people recognise that change is possible, desireable and important.